Sam's Success: Finding Pleasure Where There Was Pain

By: Shannon Pacella, DPT, PHRC, Lexington

Sam came to the Pelvic Health and Rehabilitation Center in the beginning of May this year, after her primary care physician recommended seeing a pelvic floor physical therapist as she reported having pain with vaginal penetration. Here’s what Sam had to say:

“I am 41 years old, and spent most of my life completely avoiding my vagina after experiencing severe pain with any type of penetration. This year, I realized that I was tired of the shame and frustration I felt around this, and with ignoring this very important part of my body. Years ago, my doctor had mentioned that I could use a dilator to try to stretch my vagina in hope that this would help with the pain, but at that time it sounded like an awful idea.

At my most recent yearly appointment, I re-visited this with my doctor, and she recommended pelvic floor PT. I found the Pelvic Health & Rehabilitation Center, and made the call. As a gender non-confirming queer person, I felt some hesitation about how I would be received. I was immediately assured that PHRC is a LGBTQ-affirming space. This helped me feel at ease.”

During the initial evaluation Sam told me that she has been experiencing pain with vaginal penetration, including with tampon insertion, for as long as she can remember. Sam explained to me that she thought she would never be able to experience vaginal penetration without pain, but wanted to at least try to explore this option. Sam also told me that she had a bilateral mastectomy in 2004, as well as a laparoscopic oophorectomy in 2004 due to having the BRCA gene mutation.

Sam’s goal was to have pain-free vaginal penetration, and I was determined to help her achieve this goal.

During the initial assessment I found the following:

Sam’s pelvic floor muscles (PFM) were hypertonic (had increased tightness/tension).
- These hypertonic PFM were painful when palpated/pressed on.
Impaired pelvic floor motor control: difficulty voluntarily relaxing/dropping the PFM.
- Sam was able to achieve some voluntary PFM relaxation with verbal and tactile cues, including coordinating her breathing.
Moderate connective tissue/myofascial restrictions at low back, buttocks (glutes and piriformis), posterior thighs (hamstrings), medial thighs (adductors), and bony pelvis.
Erythemic (red) vulvar tissue around the introitus (vaginal opening).

My assessment was that Sam had dyspareunia (pain with vaginal penetration) due to PFM hypertonus leading to pain with touch/stretch (which occurs during vaginal penetration) as well as impacting pelvic floor motor control. This impaired motor control does not allow for the PFM to actively contract effectively, so the muscles surrounding the pelvis, including the glutes, piriformis, hamstrings, and adductors became tight with additional connective tissue restrictions in the area. The redness/erythema at the introitus can be indicative of reduced estrogen in the vulvar tissue – this can be alleviated with the use of topical non-hormonal vaginal moisturizers but some women require the use of topical creams that contain estrogen and sometimes testosterone – I recommended she discuss this with her primary care physician.

Sam’s goals were the following:

To eliminate the PFM hypertonus.
To demonstrate good pelvic floor motor control: be able to voluntarily relax/drop PFM independently.
To be able to use dilators for HEP independently.
To report ability to have pain-free vaginal penetration.

I recommended treatment one time per week for eight to twelve visits. My treatment plan included connective tissue manipulation, myofascial release, neuromuscular reeducation, pain physiology education, home exercise program (HEP) prescription and management, therapeutic exercise and activity, activity modification, and dilator use education. We practiced pelvic floor drops/relaxations while incorporating diaphragmatic breathing, and this was given as the first part of her HEP. I also had her start doing daily hip rotator stretches and low back stretches, as well as, self myofascial release at the medial and posterior thighs with use of a myofascial release stick.

Here’s what Sam had to say after the initial evaluation:

“I felt safe, comfortable, and heard during my first appointment. I left feeling hopeful.”

At Sam’s first follow-up appointment, she reported being consistent with the HEP of self myofascial release with the myofascial stick, the hip rotator and low back stretches, and PFM drops/relaxation with diaphragmatic breathing. Sam said that she spoke with her PCP regarding the use of a vaginal moisturizer and she agreed to start with trying something non-hormonal; I recommended Vital V salve. During the treatment session, I noticed an improvement in her ability to voluntarily relax the PFM (perform a PF drop), and required less verbal cues. I added a standing hamstring stretch, a seated piriformis stretch, and to practice the PF drops in a deep squat position to her HEP.

At the next treatment session, Sam reported that all of the new stretches and exercises had been going well. She reported no low back pain and that she did some bike riding. I noticed improvements in the connective tissue and myofascial restrictions in the low back, buttocks, posterior, and medial thighs. I also noticed reduced PFM hypertonus after manual release techniques during the treatment session. Sam reported less pain to palpation of the PFM. I knew that I wanted to have Sam start using dilators to continue to improve her PFM tone and tolerance to vaginal penetration. We discussed the use of dilators, and that they are used to gently expand the vagina and allow the PFM to get comfortable with relaxing and lengthening during vaginal penetration, after the discussion Sam was on-board to try. I told her to bring in the dilators with her to her next visit so I would be able to teach her exactly how to use them.

The dilator sets that I typically recommend are:

At her third follow-up appointment, Sam said she received the dilators, (she chose the CalExotics Inspire Silicone Dilator Set). Sam reported that she was able to insert the second smallest dilator without any pain or discomfort, which made her feel very hopeful to continue this process and continue to make progress. Her connective tissue and myofascial restrictions continued to improve, as well as her PFM tone. After manually releasing and relaxing the PFM during the treatment session, Sam was able to tolerate the insertion of the third dilator without pain. The plan was to have Sam use the dilators at home for HEP, starting with the second smallest for a couple of minutes and then using the third size.

Throughout the next two treatment sessions, we were able to improve Sam’s PFM tone and motor control to be able to relax the PFM voluntarily by doing a PF drop. She was also able to independently use the dilators for home use, progressing up to the fourth size dilator. She reported that the use of the Vital V salve at the introitus seemed helpful in reducing the sensitivity/irritation of the tissue around the vaginal opening.

Here’s what Sam had to say about this experience:

“After only a few sessions with my physical therapist and the use of dilators at home, I was not only able to tolerate vaginal penetration, I was able to enjoy it. I feel so empowered. I’m so grateful for the amazing work the PHRC is doing.”

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.